Friday, April 8, 2011

"Of all the terrible chronic diseases, only one —end-stage kidney disease — gets special treatment by the federal government. A law passed by Congress 39 years ago provides nearly free care to almost all patients whose kidneys have failed, regardless of their age or ability to pay.

"But the law has had unintended consequences, kidney experts say. It was meant to keep young and middle-aged people alive and productive. Instead, many of the patients who take advantage of the law are old and have other medical problems, often suffering through dialysis as a replacement for their failed kidneys but not living long because the other chronic diseases kill them.

"Kidney specialists are pushing doctors to be more forthright with elderly people who have other serious medical conditions, to tell the patients that even though they are entitled to dialysis, they may want to decline such treatment and enter a hospice instead. In the end, it is always the patient’s choice.
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"When Congress established the entitlement to pay for kidney patients in October 1972, dialysis and transplants were new procedures that were not covered by health insurance. There were horrifying stories — rich people got dialysis and lived while poor people died. In Seattle, a committee meted out dialysis by voting on who could get it. A man who was supporting a family, for example, took precedence over a single woman.

"It also was expected at that time that fewer than 40 patients per million would need dialysis, and that most of those patients would be healthy — except for their failed kidneys — and under age 54.

"Now more than 400 people per million start dialysis each year. More than a third of the patients are 65 or older, and they account for about 42 percent of the costs. People over 75 make up the fastest-growing group of dialysis patients. And most elderly dialysis patients have other serious diseases like diabetes, heart failure, stroke and even advanced dementia. One-third of them have four or more chronic conditions.

"The federal program, said Dr. Peter S. Aronson, a professor of nephrology at Yale University’s School of Medicine “is so emblematic of good intentions misapplied.”

“The question,” Dr. Aronson said, “is how to dial it back.”

"Recent studies have found that dialysis does not prolong life for many elderly people with other serious chronic illnesses. One study found that the procedure’s main effect is to increase the chances that such patients will die in the hospital rather than at home.